Oldcourt Surgery - Travel Questionnaire

Travel Questionnaire
Please complete and submit the following travel form for the practice nurse to review. You will then need to call the practice after 5 days to book an appointment.
Personal Details
Name*

First NameLast Name
Sex*

MaleFemale
Date Of Birth*

DayMonthYear
Postcode*
Daytime Tel*
Email*
Trip Dates
Departure Date*

DayMonthYear
Return Date*

DayMonthYear
Itinerary
Country*
Duration*
Are you visiting any additional countries?

YesNo
Please list the countries and arrive/return dates below:
Trip Description - please tick all appropriate boxes:
Purpose of Trip:

BusinessPleasureOther
Type of Trip:

PackageSelf OrganisedBackpackingCampingCruise ShipTrekking
Accommodation

HotelFriends & FamilyOther
Traveling

AloneWith Friends & FamilyIn a group
Location Type

UrbanRuralAltitude
Activity Type

SafariAdventureOther
List all chronic medical conditions that you have (eg. diabetes, heart or lung conditions)
List all allergies that you have (eg. eggs, nuts, antibiotics)
If you have had a serious reaction to a vaccine in the past, which vaccine was it?
List all of your current medications (including oral contraception)
Have you recently suffered from any infection (e.g heavy cold, flu or high temperature)?

YesNo
Does having an injection cause you to feel faint?

YesNo
Do you or any close family members have epilepsy?

YesNo
Do you have any history of mental illness including depression or anxiety?

YesNo
Have you recently undergone radiotherapy, chemotherapy or steroid treatment?

YesNo
Have you taken out travel insurance?

YesNo
If you have a medical condition, have you told your insurance company about it?

YesNo
Are you pregnant, planning pregnancy or breast feeding?

YesNo
Write below any further information that might be relevant
Vaccine History

Have you ever had any of the following vaccinations / tablets and if so, when?
Tetanus
Diphtheria
Hepatitis A
Meningitis
Influenza
Jap B Enceph
Malaria Tablets
Polio
Typhoid
Hepatitis B
Yellow Fever
Rabies
Tick Borne
Other
Should be Empty:

Travel Questionnaire

Vaccine History